Tribal Healthcare

The healthcare debate is bringing out some interesting ideas. Consider what the philosopher Peter Singer (Princeton) had to say in the New York Times:

“The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.”

If the provision of and payment for healthcare were purely a matter of government policy then ideas like this might make sense.

However, having a unique hierarchy of values (aka “priorities”) is a feature of primitive tribes and comprehensive social planning. In a liberal society or “catallaxy” there are fundamental abstract rules (property, free contract, etc.) within which individuals and organizations of civil society establish their own priorities. I blogged on this general idea in a post, “The Unity of the People.”

Contrast what F.A. Hayek had to say about ideas of the kind Singer is promoting:

“…the conception of a ‘value to society’ is sometimes carelessly used even by economists… there is strictly speaking no such thing and the expression implies [a] sort of anthropomorphism or personification of society…Services can have value only to particular people (or an organization), and any particular service will have very different values for different members of society. To regard them differently is to treat society not as a spontaneous order of free men but as an organization whose members are all made to serve a single hierarchy of ends (Law, Legislation and Liberty, vol. 2., p.75).

“A free society is a pluralistic society without a common hierarchy of particular ends.” (Id., 109).

I have been fascinated for a long time by the advocacy of left-liberals of pluralism in the realm of ideas, but not in the realm of action. They seem to think of freedom as a matter of pure intellect alone. In my view, acting and thinking are two-sides of the same coin. We are not pure intellect. If we were, we wouldn’t care about healthcare.

15 thoughts on “Tribal Healthcare”

Nice quote from Hayek. But I think there is some unresolved tension in Hayek’s view here. To the extent that the value to particular individuals changes as those same individuals coalesce into a spontaneously ordered organization, then one might observe how the same organization evolves institutions that reflect “values to the organization.”

In other words, rule utilitarianism is not a perfect reflection of the aggregation of individual values, but it’s the best we can do so long as we believe the benefits of organization outweigh the costs.

The more interesting question, philosophically, is whether the granularity of the fit to individual values can be improved enough so that rule utilitarian institutions are indistinguishable from the aggregate utility that might exist in the absence of any institutions. My own answer to the question is that it’s the wrong question. On my view, aggregate utility would be much lower if everybody were disconnected. Institutions actually increase individual utility because individual utility is nonlinear beyond some threshold of social connections.

Very good. Notice however that Singer’s example assumes some fixed or finite supply of healthcare, as if “we’ve only got a 1000 healthcare units left and we need to decide how to allocate them now.” This assumed shortage exists under government-run healthcare, certainly, but not under capitalism where quantity demanded seeks quantity supplied. As long as the demand for healthcare from both the elderly individual and the young individual is supported by real purchasing power and the price system is free to adjust to such demand, both can enjoy the availability of healthcare.

Singer indeed is a utilitarian which would explain his approach, as well as his distain for individual rights (liberty, property, contract etc.).

Awhile ago I was reading an ethics book and came across a story about the early days of kidney dialysis. Since the machines were so few they appointed a committee of “experts” to determine who should receive dialysis.

“Thus, a lay committee, known as the Admissions and Policy Committee of the Seattle Artificial Kidney Center at Swedish Hospital, was formed to decide nothing less than who would be allowed to live. The committee comprised seven volunteers — a lawyer, minister, housewife, state government official, labor leader, banker, and surgeon — and was among the earliest instances, if not the first, of physicians bringing nonprofessionals into the realm of clinical decision-making. Committee members insisted on remaining anonymous so that the medical staff, the public, and especially the applicant-patients would never know their identities.”

“What happens when we get two men with the same job, the same number of children, the same income,
and so forth? Between a man with three children and a man with an older wife and six children we must, for the sake
of the children, reckon the surviving widow’s opportunity to remarry. In estimating “worth to society,” how much chance
would an artist or a composer have before this committee in comparison with the needs of a woman with six
children? Finally, if a patient is given a place in a kidney dialysis program because he “passed” a comparative
evaluation of his worthiness in terms of broad social standards of eligibility, the needs of his dependents, or his
potentiality for contribution to humanity, one can ask whether he should be removed from the program when his
esteemed character changes . . . As Dr. George Schreiner said, “You should be logical and say that when a man
stops going to church or is divorced or loses his job, he ought to be removed from the programme and somebody
else who fills these criteria substituted.”

Mario,
I frequently tell my students that these policy questions (how much should We spend on healthcare and how … ? ) are the wrong questions. Instead of asking them we should first ask “who should decide?”

Framing it this way highlights the implication that the mindset you attack assumes not so much that we all share the same priorities, as that some peoples priorities (those who lead, those who know better) should prevail over others. At least this is the “practical” implication, because everyone knows we, as individuals, have different priorities.

Would you consider the discipline of a child by a parent violence? The short answer is yes. The long answer is that it’s always nominally voluntary because of the benefits achieved in the long run by being a part of the superorganism. I’m rereading Nozick now. I think there is compatibility between Nozick and Hayek on most points. What do folks here think on that?

Context matters a lot here. As a historically descriptive matter, the answer is of course an emphatic no. The question is whether in the right (highly contingent) circumstances, state violence might be limited to that kind of (literal) paternalism. (Is this what Thaler and Sunstein have in mind with ‘Nudge’? Maybe, but if so it’s not well theorized.)

But I am really genuinely curious to know what people think about the relationship between Nozick and Hayek. Nozick is at his fuzziest when he talks about a “Lockean proviso.” What say ye?

I don’t think there is any real conflict here. Singer and other talk about “our” or “social” values. But since there is really no such thing, they wind up imposing their own values. Or the values of some special interest group.

You people seem to be taking the view that Singer wants to prevent individuals making decisions about their health care expenditure in case, or if these clash with his aged based medical treatment value calculus.

On the contrary, i took it as the perfect prelude to an argument for abolishing Medicare, and therefore for the government having less involment with health care provision.

As the enourmous expenditure on old people in the last weeks/months of life is incredibly wasteful from a Benthamite or monetary point of view, i’m inclined to agree with Singer.

Why waste enourmous sums on old people that we could instead be investing (privately or publicly), and/or give back to the taxpayer so that they can pay of their mortgages?